Dr. O'Donnell is affiliated with the Department of Psychology, St. Mary's College of Maryland, 18952 E. Fisher Rd., St. Mary's City, MD 20686 (e-mail: daodonnell@smcm.edu). Dr. Joshi is with the Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, Washington, D.C., where Ms. Lewin is with the International Center to Heal Our Children. Dr. Joshi is also with the Department of Pediatrics, George Washington University, Washington, D.C. Charles Huffine, M.D., served as guest editor of this column.

Current research on children's exposure to trauma paints a bleak picture. Both in inner-city neighborhoods and rural and suburban locales, witnessing of and victimization by violence among youths are alarmingly commonplace. More than 40% of youths in one inner-city community reported witnessing a shooting or stabbing in the preceding year (1), and 74% reported feeling unsafe in one or more common environmental contexts (2). Bullying and school violence also affect millions of youths (3).

Not only is violence responsible for much of the physical injury and death among youths in the United States, exposure to violence also has other, less obvious effects. Several replicated research studies have found exposure to violence predicts increased risk of depression, anxiety, and aggressive behavior (4,5), heightened levels of posttraumatic stress symptomatology (6), and attachment problems (7).

Sadly, the youths most at risk of such exposure are often those least likely to receive adequate services because of multiple barriers to treatment. Youths from low-income families and minority groups are at particularly high risk for both experiencing traumatic events and failing to receive timely, appropriate, and comprehensive services that target trauma symptoms (8). Data indicate that more than three million U.S. families are unable to afford private insurance and fail to qualify for Medicaid (9). In the absence of systematized and continuous professional care, these children often receive poorly coordinated, substandard services (10).

Removing such barriers to treatment is a pressing public health concern. The untreated, or inappropriately treated, aftereffects of trauma exposure can lead to the development of treatment-refractory and chronic difficulties with self-regulation and affect modulation, as well as to learning and attention deficits and problems with social relatedness (11). Mounting neuroscience evidence indicates that some changes may be longer lasting and more diffuse than previously assumed, affecting neuroendocrine, genetic, and physiological domains in an orchestrated whole-body reactionary cascade (12,13). In response to these realities, the Surgeon General has identified treatment of children's mental health disorders as a national priority (14).

To successfully address this problem, it is imperative for the mental health field to consider nontraditional methods of reaching at-risk populations. Community-based models are indicated to equip school and community personnel with the skills necessary to identify youths at risk of developing trauma symptomatology. In many cases, such school and community personnel may be the only professionals with whom at-risk children come into regular contact. This approach holds promise of both financial feasibility and effective secondary prevention.

School personnel are an ideal group of service providers to target in such an effort. Children spend more of their day in school than in any other setting. Research indicates that perceived support within the school environment serves as a robust predictor of resilience against negative outcomes among youths victimized by violence and that such support increases in magnitude over the course of a child's developmental trajectory (15). Prevention programs tailored to capitalize on this supportive role should be well positioned to harness and utilize it in novel, cost-effective ways. This column describes a training curriculum in developmental responses to trauma for school and community personnel.

The curriculum was devised on the basis of feedback garnered during focus groups with public school nurses in Washington, D.C. Focus groups, organized by the District of Columbia Departments of Health and Mental Health and District of Columbia Public Schools, along with Children's National Medical Center, were held with the school nurses to ascertain their needs as school nurses, especially as they pertained to the school environment after the September 11, 2001, terrorist attacks. School nurses from elementary, middle, and high schools participated. Information gathered from the groups indicated the wide range of roles that school nurses take on, which often includes the role of mental health counselor. Nurses serving all grades reported that they regularly encountered mental health concerns among youths in their offices; many of the concerns were related to exposure to violence in the community. They also reported that they lacked training to fulfill the mental health triage and referral roles that were expected of them in their urban school environments. They expressed a desire for mental health training in developmental responses to trauma (16).

Using information gathered through the focus groups, Children's National Medical Center's Department of Psychiatry developed and implemented a full-day training course for the D.C. school nurses. Additionally, the department was approached by the D.C. Department of Parks and Recreation, who were interested in a similar training for nomedical providers. Ultimately, four training courses were designed for four groups: 106 public school nurses and 162 employees representing three groups of Department of Parks and Recreation employees—115 recreation specialists, 39 child care workers, and eight transportation workers. One eight-hour training was held for the school nurses, two half-day workshops were held for the child care and early education providers, two eight-hour workshops were held for the recreation specialists, and a half-day workshop was held for the transportation staff.

Six trainers were used for the workshops. Trainers were doctoral- and master's-level clinicians chosen on the basis of their expertise and the target audience. Most traininers have a clinical specialty in pediatric trauma. Trainers included two child and adolescent psychiatrists (one with expertise in toddlers and preschool-aged children), one psychologist, one clinical social worker, one expressive therapist, and one master's-level public health education professional.

All training sessions took place during the normal work day during the summer and fall of 2002. Trainers were affiliated with the International Center to Heal Our Children at Children's National Medical Center in Washington, D.C., where the training sessions were held. Curriculum components were tailored to the clinical expertise of each trainer and the specific needs of each trainee group. Sessions consisted of both auditorium-style lectures and smaller break-out groups in which role plays, question-and-answer sessions, and discussion groups took place.

Each trainee group received training in nine content areas: normal responses to stress, abnormal responses to stress, posttraumatic stress disorder and acute stress disorder, stage theories of loss and grief, risk and protective factors, crisis and disaster planning, resilience, mental health referral sources, and self-care techniques for the adult caregiver. Information included in each area was compiled from a variety of sources, including undergraduate developmental textbooks and child clinical psychology textbooks as well as clinical and research data gathered by the trainers. Many of the developmental training components used in this curriculum can be found in The Handbook of Frequently Asked Questions Following Traumatic Events: Violence, Disasters, and Terrorism, which we wrote after the September 11 attacks. An online version of this handbook can be found at www.dcchildrens.com/ichoc.

Material about responses to stress was presented within a developmental framework. Participants learned about Jean Piaget's stages of cognitive development and Lawrence Kohlberg's stages of moral development; information was provided about language, motor, and socioemotional development. Trainers emphasized the ways that trauma symptoms present themselves differently among children at different stages of moral and cognitive development. In this way, participants learned how to distinguish normal or expected reactions to stress from reactions that are indicative of potential trauma.

Participants were also taught about the stages of grief as described by Elizabeth Kubler-Ross. Trainers discussed the ways in which this normal process of grieving a loss is important to chart not only for children but also for their adult caretakers. Trainers also shared with participants current and seminal research findings about the psychological impact of violence and other types of trauma on children, and neuroscience research showing brain changes among traumatized youths. [Citations for this research can be found in an online supplement to this column at ps.psychiatryonline.org.]

A 26-item multiple-choice pre- and posttraining survey was designed to measure changes in knowledge. Participants had varying levels of knowledge about developmental responses to trauma and appeared to have areas of relative strengths and weaknesses. Increases were noted in self-reported feelings of confidence in both recognizing warning signs of trauma and helping children cope with the effects of trauma. The results demonstrate that the brief training sessions appeared to have at least a short-term impact on increasing knowledge levels, particularly among child service providers with no prior training in psychology or trauma. Follow-up surveys are needed to ascertain long-term retention of knowledge and to evaluate the extent to which this model of service delivery results in actual increases in appropriate treatment referrals.

One outcome of this training initiative was the realization that increased attention to the training needs of transportation workers is important. This population represents a largely overlooked group of child service pro-viders. The transportation workers who participated in the training came to their jobs with lower levels of education than the other groups of child service providers. Because of the enclosed nature of school buses, and because children on board are making the psychological transition between home and school, transportation workers are often required to deal with some of the most extreme and important child trauma issues. Not only must they ensure that youths arrive safely at their destinations, they often must fulfill a disciplinary role as well.

Community violence is a widespread problem in the United States, especially in urban areas (17). As noted above, children exposed to violence have been shown to be at heightened risk of several clinical disorders. Many violence-exposed youths in need of mental health treatment fail to receive professional attention (18,19). As a result, mental health professionals are increasingly called upon to step outside of their traditional consultation office settings and into the community in order to bring their developmental training to community child service workers and school personnel, who interact with traumatized youths most frequently. As shown in this study, mental health professionals can provide training to equip others with the knowledge and resources necessary to improve the chances that at-risk youths will receive prompt and appropriate services.

Our findings should be viewed against methodological limitations. Follow-up investigations designed to measure long-term retention of knowledge and confidence among trainees will be important. We do not know to what degree the increases in knowledge translated into changes in trainees' interactions with children, increases in appropriate referrals, and decreases in trauma levels in the child populations with whom the trainees worked. In addition, because our sample consisted of urban school and community child service personnel, we do not know whether our findings will generalize to other groups.

Despite these limitations, our pilot study showed that brief, cost-effective training for child service providers in developmental responses to trauma appears to have at least short-term beneficial effects on levels of knowledge and confidence. It is critical to expand a community's capacity to identify and respond to the mental health needs of children. By empowering and training not only health and mental health professionals but also other providers, such as educators and recreation specialists, with an understanding of developmental responses to trauma and how and when to refer children to a mental health expert, a community can increase its ability to more quickly meet the needs of children.

The mental health field is currently faced with difficult questions regarding efficacy of treatment approaches and cost-effectiveness of traditional modes of service delivery. These issues are directly addressed in the final report of the President's New Freedom Commission, which calls for a fundamental transformation in how mental health care is delivered (20). The commission recommended an emphasis on education to assist the public in understanding that mental illness is not shameful. It also recommended that special educational attention be directed to racial and ethnic minority groups, and that children be routinely screened for mental disorders in an effort to reduce the incidence and severity of mental illness across the life span. The study presented here may be a first step in attempting to realize these goals.

Funds for the development of the training programs were provided through a contract with the District of Columbia (D.C.) Department of Parks and Recreation. School nurses employed by Children's National Medical Center to provide school nursing to D.C. Public Schools received funds through a contract with the D.C. Department of Health.

The authors report no competing interests.